All answers and information provided on this form are true, correct and complete. I have stated all my known medical and physical conditions, past and present, and acknowledge my responsibility to inform the practitioner before any future sessions commences of any changes to my medical, or physical status. I have been fully informed about the nature of the treatment to be provided. I have had the opportunity to ask questions, and have had my questions answered to my satisfaction.
I consent to the initial and ongoing consultations with the practitioner. I agree that this consent form will remain ACTIVE for future visits unless I otherwise notify the practitioner in writing